AbstractDiabetes Mellitus (DM) as ominous presumptivediagnostic of chronic kidney disease (CKD) worsening to end-stage renal damage(ESRD) is one of the spontaneous elicit in general health affair. Thelongstanding diabetes in young ages firmly evokes the exceptionalcardiovascular risk factors manifestation and the initiative progression ofdiabetic micro angiopathies and macro angiopathies. The latentpathophysiological mechanisms are strongly provocative of chronic heart failureand myocardial infarction by the potential contributor of hyperglycemia in thehemodynamic derangements confounding to the natural history of diabetes withvulnerable silent symptoms.Keywords:Coronary heart disease, ST elevation, myocardial infarction, diabeticnephropathy, chronic kidney disease, Risk of premature death.
IntroductionCardiovasculardisease constitutes the frequent dominant cause of worldwide death affectingthe youthful population (1) On clinical entitysilent MI annually experience CHD with the approximate of 9.8 million per yearpredicting the unrecognized symptoms related to the phenomenon of eitherambulatory ischemic events or unexpected death with 60%-70% c asymptomaticmanifestation.(2) The kidney disease predictionson clinical practice guidelines proves the demonstration of ischemic chest painis a strong venue of cardiovascular morbidity measures and all cause-mortality (3) with theclassification of hemo- dynamic moderations independently calculate glomerularfiltration rate (eGFR) on the scheme of arbitrary renal stages altering albuminuria, hyperfiltration and hyperglycemia in renalfailure. Consequently CKD as a clinical syndrome equivalent to CHD investigatethe urinary excretion proteins and TGF-beta 1 initially in nephropathy as adiagnostic value in clinical parameters of previous MI in diabetic individuals. (4) In theFramingham heart study, the estimation of silent ischemia detection on largescale misinterpret by atypical angina following normal ECG with theunnoticeable prevalence in broad ranging population <45years young men andwomen including the illness of metabolic impairments, eGFR fall, advanced CKDat dialysis, chronic inflammations and prothrombic attributes in the acceptableautopsy reports.
(5) Additionally diabetic kidneydisease progress with the albuminuria status and serum creatinine measurements on screening at initialconventional method in pubertal diabetic interval challenging hyperglycemia onclinical nephropathy.(6)Accordingto the Epidemiological controversies, poor estimation of CAD in CKD cases atless ratios make the diagnostic differences by the interpretation of ECGchanges, risk factor profiles, pain perception, cardiac biomarkers and MIperfusions assessment in the objective of angina culminate the presentation ofconstant changes in troponin values represent the attributes of premature CHDby the conclusion of progressive atheromatous plaques and calcifications on thelikelihood of sepsis, anemia, platelet aggressiveness, nitric oxide abnormalmetabolism, arterial stiffness, calcium-phosphate homeostasis, endothelialdysfunctions, recreational drugs, history of multiple traumas and surgeries. Classically,we present the case of inferior MI in young women with type 2 diabetesevolutions of 10 years and previous heart failure cause to death prolonging thecomplications of dyslipidemia progressive to the advancement of diabeticnephropathy in extending membranoproliferative glomerulonephritis.Case presentationA 35year old female present to Emergency Department with severe chest pain,palpitation and vomiting for 3 days. She has been diagnosed with the previousepisodes of heart failure and traditional risk factors of CAD in medicalhistory. She described her chest pain with tightedness and flank dull pain atboth the areas of kidneys with back pain.Onphysical examination, Cardiac sounds were normal on auscultation with notenderness on palpation, no intra-abdominal rebound masses, no neck stiffness,no jugular vein enlargement, no dysmenorrhea, no clubbing, no family history ofCAD and no hypertension.
She was profound sweating on presence with weightloss, urine retention, fatigability and restlessness from 1 week. Hermedications at the time of review include Aspirin, Statin, Metformin, Insulin,Diuretics and Omeprazole. At Admission, BP was 85/60mmHg and her heartrates 66 bpm. ECG showed normal sinus rhythm with ST elevation in leads II, IIIand avf with the reciprocal of ST segment depression in leads V1-V6 as shown inFig 1A The crucial step for ruling outmyocardial injury, clinical diagnosis begin with the measurement of cardiacenzymes as shown in Table 1 Moreover on theprimary assessment of troponin elevation and NT-proBNP impairment assess thespecificity and sensitivity limitations on trans-thoracic echocardiographyrevealing hypokinesia with an LVEF of48% motion index on homogenous contrast reflecting MI tension on inferior wallsuspecting intracardiac thrombosis and pulmonary embolism.Figure 1 (A) Initially ECG shows ST elevation atinferior leads with the reciprocal of ST depression in avR.
(B) No simultaneous changes in right ventricular MI on various segmentsof ECG. (C) New ST depression in the leads of II. III , and avF after followingfibrinolysis in 12 lead ECG. Table 1 Clinical values of Combined Detection of 5Indicators in the Diagnosis of Acute MI. In thesuspection of fibrinolysis and thrombo embolism, thoracic ultrasonography TUScertainly performed prior to the normal chest imaging previously and falsepositive predictive value in D-dimer test as shown in Table2 On the emergency based history of angina, bilateral thoracic probeexamine the presence of the left sided non specific pleural lesion of more than5mm on screening. It provokes the follow up of thrombolytic with theassociation of hypotension. Therefore, anticoagulation includes low-molecular-weight heparin therapy (LMWH) and tPA produce successful reperfusion within12hrs non-invasively.Table 2 Quantitative D-dimer Assay for PulmonaryEmbolism Diagnostic Test.
Inregards with Gastrointestinal aspects, the alarming signs of dehydration,nausea, vomiting, fatigue and back pain warrant the examination of a comprehensivemetabolic panel and amylase, lipase testing for the consideration ofgastroenteritis or acute pancreatitis. The normal values result self-limitingbacterial infections by the management of fluid replacement, Calcitonin andsupportive care.As thepatient on type 2 diabetes expansion on clinical estimation follow urinalysison palpation of the bladder and oliguria. According to the quantitativemeasurements on total protein positive test, the exercising ECG reviewed onhigh standards verify the reciprocal changes in pathologic Q waves and hyperacute T waves in nonfatal angina attack reflect preload independently as shownin figure 1B Apart from the renal profile, furtherglobulin tests were progressed on the basis of laboratory evidences as shown inTable 3 – 4 decline in eGFR, leucocytosis and elevated cholesterol conclude thepathogenesis of contrast induced nephropathy in association of nephrotoxicdrugs eliminating the advanced staging of kidney damage other thanglomerulonephritis and residual renal dysfunctions.Table 3 Comprehensive Metabolic Panel with eGFRBlood Test. Table 4 Complete Blood Count Test Results. On thebasis of ANA negative investigation, monoclonal immunoglobulin IgG determinethe pre-malignancy in renal insufficiency with plasmapheresis at high risk of multiplemyelomas as shown in Table 5 here in thediagnosis of proteinuria and myeloma related diseases Bence Jones test revealfalse negative results in concentrated urine.
At result, vitamin K status inCKD sub clinically link to the formation of arterial calcification in the highmoderations of atherosclerosis constitute the notable limitations onindependent peritoneal dialysis to maintain the equivalent nutrition at theless co-morbidity of young age in CKD.Table 5 Serum Protein Electrophoresis to diagnose Mprotein. Differential DiagnosisPrinzmetals angina/vasospasm, cardiogenic shock, cardiac contusion, pulmonary edema,acute gastritis, GERD and anxiety disorders are unlikely considered on pursuedclinical presentation as reviewd. TreatmentManagementis initiative with the long-lasting insulin therapy in type 2 diabetes with thecombination of Sulfonylurea and Metformin to control hyperglycemia.
Secondlyuse of diuretics to restore electrolyte imbalance and Vitamin C for the nauseatefeeling. Thirdly Diazepam orally for the anxiety and cardiac therapy Cedilanidfor hemodynamic stability, Dopamine hydrochloride for improving the cardiacfunctions, Hydroxylamine and MgSO4 to control frequent arrhythmias, Clopidogrel150mg + Aspirin 100mg with heparin therapy of LMWH in the preventions of heartfailure and recurrent myocardial infarction. Lastly IV Sodium bicarbonate+insulin+ 50% Dextrose for hyperkalemia and Atorvastatin of 20mg oral/day forLDL reduction.Follow upOn theNinth day, ECG changes as shown in fig 1C, ST resolutionand T wave inversion after the pharmaceutical drugs. At practical measures IVhuman albumin infusion as a therapeutic plasmapheresis remarkably improved thetailored indication of hypovolemic shock in the significance of cardiacimprovement. Hence at the objective of primary care with proper monitoring of stablerenal functions by calcium gluconate, on fifteenth day patient discharged witheffective diet planning assumed by community-based clinicians in providing selfmanagement to control delicate balance in postprandial hyperglycemiaadjustments. Discussion The DIAD(Ischemia detection in asymptomatic Diabetics) (5, 7) assumesthe importance of greater incidence in long standing type 2 diabetes mellitusfocus on the factor of occlusion in arteries on the possibility of judiciousanalyses with no support of scientific data in the management of anti-ischemicmedications at frequent CAD cases. Hence, the investigations of massiveconsequences intermediate undoubtedly on clinical scoring as addressed for theissue of positive prognostic screening program in the upcoming studies.
American Diabetes Association (ADA) recommend the measures of Beta blockers orre-vascularization medical therapy on aggressive intensive treated cases oninvestigating the annual review of abnormal resting ECG with the lesser degreesof ischemia intervention can improve the prognosis on cardiovascular events.The nontraditional factors of hyper coagulation and clotting mediators (8) pronounce the elevation of high risk on thrombicevents statistically with the complications of CKD underlying the unclear etiologypredominantly result congestive heart failure, ESRD, hemorrhagic stroke andrelative risk of peripheral artery disease proportional to sudden cardiacdeath. Thus, an appropriate medical therapeutic management needed in terms ofrisk factors incidental preventions in adult onset diabetes.
(9) Inprimary prevention study at Helsinki Heart Study (10) showpoor outcomes in Diabetic individuals with CHD identifying high risk ofaggressiveness in dyslipidemia treatment for the maintenance of LDL and Totalprotein target the statin drugs as a pharmacological intervention for thetrials as a first choice in young diabetic nephropathy patients. The GeneralPractice Research thrombosis Prevention trial (11)on the secondary prevention confirm thebenefit of Aspirin treatment in the establishment of atherosclerotic disease inprospective trials reduced the risk of CHD and non fatal events on the clinicalrecommendation of anti-platelet therapy can also be used as a preventivestrategy to overt the nephropathy in <30 years age individuals. Thereforelarge phase prospective studies and trials are required to explain the issuesof uncertain protein restriction in the adherence of management in routinesetting care in diabetic nephropathy. ObservationalStudies in the demonstration of direct effect on CVD risk factors deteriorate thekidney functions in hyperglycemia. The Reduction of End points inNon-insulin-dependent Diabetes with the Angiotensin II Antagonist Losartan(RENAAL) and Irbesartan Diabetic Nephropathy Trial (IDNT) studies include thetrial of Losartan and Iresartan as a renoprotective in the combination ofRamipril and Telmisartan initiate the defensive effect on proteinuria ascompared to the therapy of (VA NEPHRON-D) study of Losartan and Lisinopril onmacroalbuminuria >300mg/day.
Thus, the supportive directions on definitelimitations of safety concerns utilize the consideration of Renin AngiotensinAldosteron System (RAAS) lessens micoalbuminuria 30-300mg/day in normicdiabetes cases. (12) Hyperglycemiaas a therapeutic potent in diabetes, the epidemiological early analysisillustrate the fundamental controversy of minimal outcomes in macrovascularhazards can ascend the occasion of CVD risk factors, extravagant mortalityrates and vigorous symptoms with the median of HbA1c%. The Action in ControllingCardiac Risk factors in Diabetes (ACCORD) present the current affirmation ofdelaying vascular complications related to the consequences of CKD staging 3-4can be patently achieved by the optimal goal of HbA1c and hypoglycemiaincidents. Accordingly, a tight control on hyperglycemia is permeable toconvert the high risk of hyperfiltration and glomerular hypertrophy partiallyon HbA1c <7% and apparent supremacy to control the normal ranges with thetreatment of insulin in the maintenance of proteinuria on reduced value.
According to the American Heart Associationguidelines, the pharmacotherapy in CKD associated with CVD risk factors includethe counsel use of Fibrinolytic, Antiplatelet, Glycoprotein II b/III a receptorantagonist, Anti-coagulants, Beta blockers, ACEIs/ARBs, Aldosterone blocker andStatin can assess the randomized controlled trials of efficacy and welfare todiminish the vascular events in non chronic dialysis patients. The another Studyof Heart and Renal Protection (SHARP) involve the substantial results incombined therapy composite to the dominance in controlling the majoratherosclerotic relative risks, intracranial hemorrhage, left ventricularhypertrophy and STEMI intimated the remarkable decline in hospital death and suddencardiac arrest for least 1 year. Ultimately, pharmacokinetic studies in renaldysfunction require essential regulations for the clinical controlled trialsfurther on extensive population with distinct precise dosing in terminating thepredictable adverse outcome pathways.Learning points· STEMIfeature exceeding QRS height in the form of concave ST elevation.
· Antihypertensiveas a binary therapy of ACEI and ARBs are used in supremacy of BP andalbuminuria.· Combinedtherapy with oral insulin agents should be sustained with HbA1c <7%· Importanceof anti-ischemic and anti-thrombic therapy must be understood as a conservativestrategy in <40 age with vascular disease, diabetes and STEMI· Earlyscreening detection in the initiative of type 2 diabetes kidney relatedcomplications. · Determinedlifestyle remodeling guidance is paramount in cardiovascular risk factors.